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x4�'k��8� <br /> `� STATE ID NUMBER 00000034919001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> Q() 01 NEW PERMIT ( 1 05 RENEWED PERMIT 7 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> rT 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> CITY OF LODI ( ) 01 FED ( ) 02 STATE ) 03 LOCAL <br /> STREET ADDRESS CITYSTATE ZIP <br /> 221 W. PINE ST LODI CA 95240 <br /> II FACILITY <br /> FACILITY NAMErr� �(1 1 DEALER/FOREMAN/SUPERVISOR '� �" I <br /> PUBLIC SAFETY BUILDING � �f. 0T � ( RICHARD WIECH2 �� ,�I-(00ar(TCI�G^cc J FPr h7EHC{6'K <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 230 W. ELM ST CHURCH <br /> CITY COUNTY ZZP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 221 W. PINE ST. — �l 3 Q LODI CA 95240 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> B17OeJ100.0009. 2O9"33°/•�` ( ) 01 GASOLINE STATION (X) 02 OTHER POLICE/FIRE DEPT. <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 2 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME PIRST) AND PHONE W/AREA CODE <br /> LODI FIRE DEPT 209-369-3521 ( y,.,6AgF i 50. Q.—. -.30' 3572 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( l 04 OTHER: CONTAINER NUMBER 230-1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: 1975C. YEAR INSTALLED 1975 ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 10000 GALLONS ( I UNKNOWN E. DOES THE CONTAINER STORE: ( l 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( l 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> f 1 01 UNLEADED ( ) 02 REGULAR ( 1 03 PREMIUM S.xl'04 DIESEL f 1 05 WASTE OIL C ) 06 OTHER 22 f�,e/ C)( <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS Of PRIMARY CONTAINMENT: 1/4 ( 1 GAUGE (X) INCHES ( ) CM ( ) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( l 03 LINED <br /> D. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 7 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE f ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( 7 07 STEEL CLAD ( ) 08 BRONZE ( 1 09 COMPOSITE ( 7 10 NON-METALLIC <br /> ( 7 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />